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HX64067238 
RD86.E9  L97  More  ether :  less  ch    - 

/£  OTe    EIJH  ER;    less 
CHLOROFORM 


BY 

JOSEPH  E.  LUMBARD,  M.D. 
NEW  YORK 


Reprinted  from  the  Medical  Record 
Decemter  i,  1006 


WILLIAM  WOOD  &  COMPANY 

NEW   YORK 


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L91 


MORE  ETHER;  LESS  CHLOROFORM.* 

By  JOSEPH  E.  LUMBARD,  M.D., 

NEW  YORK. 
ANESTHETIST    TO    THE   HARLEM    HOSPITAL 

There  are  few  subjects  to  which  a  medical  student 
gives  less  attention  than  that  of  anesthetics.  Sir 
Frederick  Treves  said :  "There  is  a  widespread  im- 
pression that  to  give  chloroform  is  a  minor  act;  the 
power  comes  with  the  diploma,  and  the  significance 
is  sometimes  emphasized  by  the  remark:  'Well,  if 
a  man  cannot  give  chloroform,  what  can  he  do  ?'  " 

Ether  and  chloroform  are  still  our  chief  anesthet- 
ics, and  have  been  rivals  for  the  surgeon's  favor  for 
more  than  "half  a  century.  Ether  is  often  preceded 
by  nitrous  oxide  or  ethyl  chloride,  either  of  which 
renders  the  administration  shorter,  safer,  and  pleas- 
anter. 

Contrast  the  old  way  of  strangling  the  patient  into 
insensibility  by  the-cone  method,  with  practically  no 
air,  and  that  of  using  gas  or  ethyl  chloride  as  a  pre- 
liminary, and  the  patient  knowing  nothing  of  taking 
ether.  A  medical  friend  who  had  experienced  both 
ways  said  he  knew  of  no  more  striking  illustration 
of  hell  and  heaven  than  taking  ether  by  the  two 
methods  mentioned. 

Nitrous  oxide  is  the  safest  and  most  agreeable  an- 
esthetic and  it  is  by  far  too  little  understood  and 

*Read  before  the  meeting  of  the  Harlem  Medical  Asso- 
ciation, October  3,  1906. 

Copyright,  William  Wood  &  Comnanv 


used.  This  is,  perhaps,  natural,  as  our  medical  col- 
leges teach  too  little  about  it.  Furthermore,  it  is  not 
always  easy  to  obtain,  and  the  instrument  for  its 
proper  administration  is  quite  expensive. 

I  highly  recommend  it  for  simple  operations,  or 
those  of  short  duration,  or  for  painful  examinations 
and  dressings.  It  is  not  contraindicated  when  heart 
or  lung  disease  is  present,  but  it  should  not  be  em- 
ployed in  cases  with  arterial  degeneration  or  with 
aneurysm.  In  young  children  under  the  age  of  five 
years  ether  is  preferable.  Its  most  important  use 
in  surgery  at  the  present  time  is  as  a  preliminary  to 
ether.  Given  in  this  way,  it  greatly  lessens  the  pa- 
tient's suffering  and  is  a  time  saving  measure. 

Ethyl  chloride  has  been  favorably  known  for 
many  years  as  a  local  anesthetic,  but  for  the  past  few 
years  it  has  been  used  as  a  general  anesthetic,  and 
in  many  localities  it  is  trying  to  displace  nitrous 
oxide  in  general  surgery,  especially  as  a  preliminary 
to  ether.  The  inhalers  for  its  administration  are  too 
numerous  to  mention. 

For  short  operations,  needing  more  prolonged 
and  deeper  narcosis  than  is  usually  obtained  by  ni- 
trous oxide,  ethyl  chloride  is  of  advantage.  It  is 
also  better  for  children  than  nitrous  oxide.  It 
should  not  be  used  in  cases  where  there  is  much 
thickening  of  the  tissues  of  the  neck,  as  in  laryn- 
gitis. Its  use  is  also  contraindicated  in  neurotic  and 
alcoholic  patients.  Although  ethyl  chloride  is  cheap 
and  easy  to  carry  around  and  administer,  we  should 
not  lose  sight  of  the  most  important  fact  that  it  is 
not  as  safe  as  nitrous  oxide.  Thos.  D.  Luke,  Edin- 
burgh, in  the  Lancet,  May,  1906,  reports  22  deaths, 
and  W.  J.  McCardie,  British  Medical  Journal, 
March  17,  1906,  reports  38  deaths  from  its  use. 

For  practical  purposes  we  might  say  that  ethyl 
chloride  is  to  nitrous  oxide  as  chloroform  is  to  ether. 


Other  anesthetics  and  drugs  sometimes  used  in 
combination  with  ether  and  chloroform  are :  Scopo- 
lamine,- somnoform,  morphine,  and  atropine.  Scopo- 
lamine is  usually  given  in  doses  of  from  1-150  to 
i-ioo  gr.,  combined  with  1-8  to  1-4  gr.  of  morphine 
in  from  one  to  three  doses,  administered  from  one- 
half  to  one  and  one-half  hours  before  the  operation, 
preferably  in  divided  doses.  The  long  and  disagree- 
able after-effects  and  the  numerous  deaths  reported 
from  its  use  will  prevent  the  drug  from  becoming 
popular,  although  many  French  and  German  an- 
esthetists continue  to  use  it  without  hesitation  and 
with  reported  good  success. 

Somnoform  is  merely  a  mechanical  mixture  of 
ethyl  chloride  (60  per  cent.),  methyl  chloride  (35 
per  cent.),  and  ethyl  bromide  (5  per  cent.).  It  is 
more  expensive,  leaves  a  very  disagreeable  odor,  and 
has  an  unpleasant  effect  upon  the  patient.  It  is  not 
considered  as  safe  as  pure  ethyl  chloride. 

A  hypodermic  injection  of  morphine  from  1-8  to 
1-4  gr.,  with  or  without  atropine  sulphate  1-150  to 
i-ioo  gr.,  is  often  given  from  twenty  to  thirty  min- 
utes before  operation  in  alcoholics  and  athletes. 

Atropine  is  often  used  hypodermically  in  cases 
where  the  mucous  secretions  are  excessive  along  the 
respiratory  tract ;  also  to  stimulate  the  heart. 

Ether. — As  the  usual  modes  of  administering 
ether  are  well  understood,  I  will  refer  only  to  two 
that  are  of  value,  but  not  generally  recognized — 
namely,  the  drop  method,  and  ether  narcosis  ob- 
tained by  giving  warm  ether  vapor  per  rectum. 

The  drop  method  should  begin  slowly,  as  with 
chloroform.  The  most  simple  and,  to  my  mind,  one 
of  the  best  ways  of  giving  it  is  by  the  open,  contin- 
uous method,  after  the  so-called  surgical  stage  has 
been  attained  by  gas-ether  with  the  Bennett  inhaler. 
Many  fail  in  this  method  because  they  use  too  small 


a  mask,  or  do  not  constantly  drop  the  ether.  A 
mask  is  used  similar  to  the  Esmarch,  but  larg'er,  and 
is  covered  with  two  thicknesses  of  stockinette ;  the 
ether  is  dropped  constantly,  from  120  to  150  drops 
per  minute,  until  the  face  flushes  or  the  patient  feels 
drowsy;  then  extra  gauze  is  applied  and  the  ether 
continued  until  the  patient  is  well  under  its  influ- 
ence; the  extra  gauze  is  then  removed  and  the  ether 
continued  as  before.  This  simple  and  safe  method 
has  much  to  recommend  it.  The  patient's  breathing 
and  appearance  are  more  natural  than  under  any 
other  method  of  anesthesia,  his  recovery  is  rapid, 
and  disagreeable  after-effects  are  usually  absent. 

This  method  is  highly  recommended  for  children 
and  old  people.  Miss  Alice  Magaw,  anesthetist  to 
Drs.  Charles  and  William  Mayo  of  Rochester, 
Minn.,  has  used  it  exclusively  in  over  14,000  cases 
without  any  deaths  or  serious  results.  Even  the 
struggling  and  feeling  of  strangulation  rarely  occur 
by  this  method.  For  a  dropper  I  recommend  a  wick 
made  of  gauze  or  cotton,  and  placed  alongside  the 
cork  in  the  original  ether  can.  It  is  simple  and  con- 
venient and  always  easy  to  obtain. 

Rectal  etherization  was  first  attempted  by  Dr. 
Pirogofif  in  1847.  Drs.  Robert  F.  Weir  and  William 
T.  Bull  tried  it  iii  several  cases  in  1884,  but  with 
only  partial  success.  Drs.  John  H.  Cunningham  and 
F.  H.  Lehay  of  Boston,  Mass.,  have  obtained  most 
excellent  results  with  this  method  and  have  a  record 
of  over  one  hundred  cases.  The  first  important  pre- 
liminary to  this  method  is  that  the  patient  must  be 
on  a  low  diet  for  two  or  three  days  before  the  oper- 
ation. A  saturated  solution  of  magnesium  sulphate, 
two  ounces,  should  be  given  twice  before  the  opera- 
tion. Sufficient  time  should  elapse  between  the 
doses,  so  that  the  effects  of  one  may  be  obtained  be- 
fore the  other  is  given.     As  many  enemata  should 


be  given  as  are  necessary  to  make  the  rectum  clean. 
Breakfast  before  the  operation  should  consist  of  two 
ounces  of  beef  tea.  The  rectum  must  be  entirely 
emptied  of  all  liquids  and  gases.  A  bottle  with  a 
capacity  of  34  ounces,  containing  29  ounces  of  ether, 
is  placed  in  a  bath  of  warm  water  of  from  80°  to 
90°  F.  A  rectal  tube  is  then  introduced  from  ten 
to  fourteen  inches  and  the  warm  ether  vapor  is 
pumped  into  the  rectum  until  the  patient  is  well  nar- 
cotized. The  apparatus  resembles  the  Junker  in- 
haler, except  that  the  bottle  is  larger  and  the  out- 
going tube  connects  with  the  rectal  tube.  Two  or 
three  compressions  of  the  bulb  per  minute  will 
usually  suffice.  This  method  affords  the  surgeon 
a  free  field  in  operations  upon  the  head,  face, 
mouth,  nose,  throat,  ear,  and  neck,  and  is  also  of 
value  in  patients  suffering  from  lung  trouble.  The 
absence  of  the  ether  inhaler  in  operating  on  the 
head,  face,  and  neck  not  only  lessens  the  technical 
difficulties  of  the  operator,  but  also  the  chances  for 
sepsis.  The  patient  is  easily  affected,  there  is  no 
sense  of  suffocation,  less  ether  is  used,  the  stage  of 
excitement  is  absent,  and  recovery  is  more  rapid  and 
less  disagreeable.  Patients  who  have  taken  ether 
by  inhalation  and  per  rectum  prefer  the  latter 
method.  There  are  no  disadvantages,  excepting  in 
some  cases  a  few  colicky  pains. 

Another  advantage  of  this  method  is  that  the 
rectal  administration  of  ether  takes  the  place  of 
chloroform,  which  has  always  been  used  almost  ex- 
clusively for  head  surgery.  Ether  is  safer,  and  the 
anesthetist  is  out  of  the  surgeon's  way. 

The  objections  to  ether  are  its  irritability  to  the 
air  passages,  the  nausea  and  vomiting,  and  the  cere- 
bral excitement.  Ether,  as  is  well  known,  is  in- 
flammable, but  if  used  below  the  level  of  the  arti- 
ficial light  there  is  practically  no  danger.     Another 


objection  is  the  possibility  of  causing  ether  pneu- 
monia. These  are  all  minimized  by  the  preliminary 
use  of  nitrous  oxide,  and  by  the  drop  method;  also 
by  the  rectal  method.  Washmg  out  the  stomach 
after  giving  ether  greatly  lessens,  and  oftentimes 
completely  does  away  with,  postoperative  vomiting. 
The  lavage  should  be  immediately  after  the  opera- 
tion, before  the  patient  regains  consciousness.  The 
drop  method  will  greatly  lessen  the  possibility  of 
pneumonia,  and  I  have  never  heard  of  its  occurring 
in  cases  of  narcotization  by  the  rectal  route.  Ether 
pneumonia  is  claimed  to  be  caused  by  the  anesthetist 
and  not  by  the  anesthetic. 

The  advantages  of  ether  are  :  ( i )  The  first  and 
all  important  advantage  is  its  safety.  (2)  It  is  stim- 
ulating, whereas  chloroform  is  depressing.  This 
can  well  be  demonstrated  when  you  have  a  flagging 
pulse  under  chloroform,  and  change  to  ether.  (3) 
Ether  will  stand  more  abuse  than  chloroform,  which 
is  a  great  advantage  when  one  is  obliged  to  have  a 
novice  administer  the  anesthetic.  (4)  Ether  usually 
gives  warning  of  approaching  danger,  which  chloro- 
form seldom  does.  (5)  The  practical  working  range 
of  ether  is  much  wider  and  there  is  less  fear  of  acci- 
dent from  an  overdose  than  when  chloroform  is 
used. 

In  this  connection  it  may  be  said  that  more  than 
65,000  persons  have  been  etherized  at  the  Massachu- 
setts General  Hospital  and  the  Boston  City  Hos- 
pital, and  as  far  as  can  be  ascertained  there  has  not 
been  a  single  death  due  solely  to  the  anesthetic.  (See 
G.  W.  Gay,  International  Textbook  of  Surgery,  p. 
421.)  In  New  York  City,  according  to  the  records 
of  the  Board  of  Health,  communicated  to  me  of- 
ficially by  Chas.  J.  Burke,  M.  D.,  the  Assistant  Reg- 
istrar, from  1 90 1  to  1905  the  deaths  from  chloro- 
form numbered  40;  from  ether  21.    Considering  the 


immensely  larger  number  of  etherizations,  this 
shows  ver)^  forcibly  how  much  safer  ether  is  as  an 
anesthetic. 

The  contraindications  of  ether  are:  (i)  Pro- 
tracted operations  about  the  mouth,  jaw,  nose,  and 
pharynx.  The  contraindications  in  these  cases  can 
be  overcome  by  the  rectal  method.  (2)  All  opera- 
tions requiring  the  use  of  the  actual  cautery.  (3) 
Any  acute  pulmonary  irritation,  or  advanced  or 
acute  renal  disease.  However,  the  use  of  ether  can- 
not be  excluded  by  any  hard  and  fast  rule. 

Chloroform. — When  chloroform  is  given  by  the 
open  mask  method  the  patient  should  always  have 
plenty  of  air.  Our  English  friends  go  as  far  as  to 
say  that  the  mask  never  should  touch  the  face.  The 
Junker  inhaler  is  often  used  in  head  surgery.  Its 
principal  advantage  is  that  the  vapor  is  pumped 
through  a  tube  through  the  mouth  or  nose.  Chloro- 
form is  not  inflammable,  and  were  it  not  for  its  dan- 
gers it  would  be  an  almost  ideal  anesthetic.  Chem- 
ically, it  is  very  sensitive.  Light  plus  air  may 
change  it.  It  should  be  used  from  the  original  bot- 
tle.    Dust  will  change  chloroform,  but  not  ether. 

Chloroform  should  be  administered  very  grad- 
ually ;  pushing  it  is  dangerous,  and  it  is  here  that  the 
accidents  attending  its  use  are  most  frequent.  The 
patient  is  restless ;  the  surgeon  is  ready  to  operate ; 
the  anesthetist,  perhaps  a  junior,  without  proper 
training  or  experience,  fearing  the  displeasure  of 
the  surgeon,  pushes  the  chloroform ;  in  fact,  often- 
times he  is  told  to  do  so ;  the  patient  breathes  deeply 
and  you  get  the  toxic  effects  of  the  drug  and  some- 
times a  fatal  issue.  Most  deaths  from  chloroform 
have  occurred  during  the  first  few  minutes  of  its 
administration,  and  this  is  one  reason  why  it  should 
not  be  used  for  the  removal  of  adenoids  or  other 
short  operations,  as  is  commonly  done. 


The  advantages  of  chloroform  are  that  it  has  an 
agreeable  odor ;  it  is  less  irritant  to  the  air  passages 
than  ether;  it  is  less  apt  to  cause  nausea  and  vomit- 
ing; it  occupies  less  space,  which  is  an  advantage  in 
the  army  and  navy  service,  and  it  is  not  so  expensive 
to  buy  or  administer. 

Its  one  great  disadvantage,  which  overshadows 
all  the  points  in  its  favor,  is  the  danger  attendmg  its 
use.  In  spite  of  this,  it  will  always  be  the  leading 
anesthetic  in  warm  countries,  as  ether  boils  at  96° 
F.,  and  is  not  practical  for  use  excepting  by  the 
closed  method  in  such  climates. 

Chloroform  is  usually  preferred  in  patients  with 
renal  or  pulmonary  disease,  in  brain  surgery,  and  in 
tracheotomy.  Probably  its  greatest  field  of  useful- 
ness is  in  obstetrics.  Here  the  element  of  fear, 
which  has  been  so  well  described  by  Dr.  John 
Bodine,*  is  practically  nil,  as  the  patient  welcomes 
anything  that  will  put  an  end  to  her  labor  pains. 

When  chloroform  is  indicated,  care  and  proper 
management  in  its  administration  greatly  lessen  its 
dangers.  It  is  contraindicated  in  cases  of  fatty 
heart,  in  lymphatic  conditions,  and  in  adenoids. 

Chloroform  certainly  has  its  field  of  usefulness, 
but  I  think  it  is  often  used  where  ether  could  and 
should  be  more  safely  substituted.  This  is  especially 
true  in  the  two  very  common  operations  for  adenoids 
of  the  pharynx  and  curettage  of  the  uterus.  Dr. 
T.  D.  Luke  reports  30  deaths  from  1897  to  1903- 
from  chloroform  administered  for  adenoid  opera- 
tions. 

Comparative  merits  of  ether  and  chloroform. — 
Ether  is  slower  in  its  effect,  less  pleasant  to  inhale, 
more  bulk}^,  and  more  expensive;  it  is  inflammable, 
sometimes  irritating  to  the  air  passages,  and  is  often 

*International  Clinics,  Vol.  Ill,  Twelfth  Series. 


followed  by  nausea  and  vomiting;  however,  it 
usually  gives  warning  of  danger,  and  is  safe  under 
ordinary  circumstances. 

On  the  other  hand,  chloroform  is  quicker  in  its 
effect,  pleasant  to  take,  less  irritating  to  the  mucous 
membrane,  less  bulky  and  less  expensive;  it  is  not 
explosive,  and  usually  causes  less  nausea  and  vomit- 
ing ;  it  does  not  always  give  warning  of  danger,  and 
is  not  always  safe. 

The  merits  of  each  case  must  be  carefully  consid- 
ered when  selecting  the  anesthetic,  and  neither 
chloroform  nor  ether  should  be  used  exclusively. 
Ether,-  however,  being  the  safer,  should  always  have 
the  preference  when  it  is  not  contraindicated.  After 
all  is  said,  it  is  experience  that  counts  more  than  the 
anesthetic,  or  the  apparatus  that  is  used. 

In  order  to  ascertain  the  views  of  one  hundred 
surgeons  throughout  the  United  States,  I  sent  to 
each  one  a  letter,  of  which  the  following  is  a  copy : 

August  1 8,  1906. 
Dear  Doctor :— . 

I  am  endeavoring  to  ascertain  the  relative  favor 
in  which  ether  and  chloroform  are  now  held  by  the 
general  surgeons  in  this  country,  and  with  that  pur- 
pose in  view  I  have  taken  the  liberty  of  sending  you. 
among  others,  a  copy  of  the  following  list  of  ques- 
tions. The  replies  to  these  will  be  embodied  in  a 
paper  on  "More  Ether;  Less  Chloroform,"  which  I 
expect  to  read  before  the  Harlem  Medical  Associa- 
tion of  New  York  on  October  3,  1906. 

1.  Which  anesthetic  do  you  prefer  in  general 
surgical  work?    (a)   Ether?    (b)   Chloroform? 

2.  Which  method  of  administration? 

3.  As  preliminary  to  the  use  of  ether,  do  you  pre- 
fer (a)  Nitrous  oxide?    (b)  Ethyl  chloride? 

4.  In  your  opinion,  do  you  think  anesthetics  and 


their  method  of  administration  receive  proper  ^at- 
tention in  the  curriculum  of  our  medical  college*? 

5.  How  many  deaths  have  come  under  your  ob- 
servation from  the  administration  of  (a)  Ether? 
(b)  Chloroform? 

Thanking  you  in  advance  for  your  courtesy,  I  am 

Yours  very  truly,  ■ 

Seventy  nine  answers  were  received  from  the 
following  surgeons  in  twenty-three  States  :  Robert 
Abbe,  W.  S.  Bainbridge,  Carl  Beck,  J.  A.  Blake,  J. 
A.  Bodine,  G.  E.  Brewer,  Leroy  Broun,  J.  D. 
Bryant,  W.  B.  De  Garmo,  H.  B.  Delatour,  C.  N. 
Dowd,  Ellsworth  Eliot,  Jr.,  C.  A.  Elsburg,  J.  F. 
Erdmann,  R.  Guiteras,  Frank  Hartley,  H.  A.  Hau- 
bold,  I.  S.  Haynes,  J.  W.  Hearn,  J.  J.  Higgins, 
L.  W.  Hotchkiss,  L.  J.  Ladinski,  W.  G.  Le  Bou- 
tillier,  H.  Lilienthal,  S.  Lloyd,  W.  H.  Luckett, 
Willy  Meyer,  Robert  T.  Morris,  A.  V.  Mosch- 
cowitz,  L.  S.  Filcher,  J.  D.  Rushmore,  H.  Roth, 
Parker  Syms,  M.  W.  Ware,  Joseph  Wiener,  Jr., 
Robert  F.  Weir,  and  J.  A.  Wyeth,  New  York; 
Lewis  L.  Basher  and  Stuart  McGuire,  Rich- 
mond, Va. ;  F.  E.  Butts  and  G.  W.  Crile,  Cleveland ; 
A.  E.  Cabot,  D.  W.  Cheever,  G.  W.  Gay,  F.  W. 
Harrington,  M.  H.  Richardson,  and  J  C.  Warren, 
Boston ;  William  H.  Carmalt,  New  Haven ;  John  B. 
Deaver,  Richard  H.  Harte,  J.  W.  Hearn,  and  Ed- 
ward Martin,  Philadelphia;  W.  H.  Doughty,  Au- 
gusta, Ga. ;  Duncan  Eve,  Nashville ;  Leonard  Free- 
man and  C.  A.  Powers,  Denver;  F.  N.  Gerrish  and 
Seth  Chase  Gordon,  Portland,  Me. ;  John  M.  Gile, 
Hanover,  N.  H. ;  W.  S.  Halsted,  Baltimore ;  Thomas 
W.  Huntington,  San  Francisco  ;  Edward  J.  Ill,  New- 
ark, N.J. ; Robert  W.  Johnson  and  Howard  A.  Kelly, 
Baltimore ;  A.  F.  Jones,  Omaha ;  W.  McD.  Martin, 
Mobile;  Archibald  MacLaren,  St.  Paul;  Chas.  H. 

10 


Mayo  and  Wm.  J.  Mayo,  Rochester,  Minn. ;  John  B. 
Murphy,  A.  J.  Ochsner,  and  N.  Senn,  Chicago;  Ros- 
•,vell  Park,  Buffalo ;  H.  H.  Mudd,  St.  Louis ;  Man- 
rting  Simons,  Charleston,  S.  C. ;  F.  D.  Smyth, 
Memphis ;  Bacon  Saunders,  Ft.  Worth,  Texas ;  H. 
C.  Tinkham,  Burlington,  Vt. ;  A.  Vander  Veer,  Al- 
bany, N.  Y. ;  G.  E.  Vaughan,  Washington,  D.  C. 

The  following  is  a  summary  of  the  answers  re- 
ceived : 

Question  i.  Sixty-seven  preferred  ether;  7  chlo- 
roform ;  I  anesthol ;  4  were  noncommital. 

Question  2.  In  the  case  of  ether,  38  used  the 
drop  method;  16  the  Bennett  inhaler;  11  the  cone; 
8  the  Allis  inhaler ;  i  the  Blake  inhaler.  If  chloro- 
form were  used,  11  preferred  the  drop  method,  i 
the  vapor  method. 

Question  3.  Forty-eight  nitrous  oxide;  3  ethyl 
chloride ;  3  morphine  hypodermically ;  i  morphine 
and  scopolamine  hypodermically;  i  A.-C.-E.  mix- 
ture ;  I  anesthol  occasionally ;  20  nothing  or  non- 
committal. 

Question  4.  Sixty-eight  answered  in  the  nega- 
tive. 

Question  5.  Ether,  53  deaths ;  chloroform,  91 
deaths. 

The  answers  to  these  questions  are  most  interest- 
ing and  of  very  great  importance.  They  show  that 
there  has  come  to  be  an  almost  universal  consensus 
of  opinion  in  favor  of  ether,  excepting  under  very 
special  circumstances.  Considering  that  chloroform 
is  so  much  easier  of  administration  and  has  less 
inconveniences,  this  is  a  very  striking  tribute  to  the 
safety  of  ether.  The  collected  statistics  show  that  a 
revolution  has  been  effected  in  this  matter  in  the 
last  twenty-five  years.  While  there  used  to  be  many 
men  who  preferred  chloroform,  now  these  are  but 
few.     Of  all  who  have  answered  the  question  di- 


II 


rcctly,  67  prefer  ether,  7  prefer  chloroform,  i  an- 
esthol,  and  4  are  not  committal. 

The  question  of  a  preliminary  to  the  use  of  ether 
now  interests  every  surgeon  without  exception.  A 
few  years  ago  no  one  thought  of  the  strangling  of 
the  patient;  now  everyone  considers  this  sufficient 
to  justify  going  to  considerable  expense  and  trouble 
in  order  to  prevent  it.  Within  the  next  five  years 
no  one  will  think  of  administering  ether  without 
having  some  method  of  preliminary  narcosis.  This 
is  a  decided  humanitarian  advance. 

All  are  agreed  that  enough  attention  is  not  paid 
to  the  teaching  of  the  administration  of  anesthetics 
in  our  medical  schools.  I  should  not  say  all,  be- 
cause there  are  a  few  men  who  consider  that 
sufficient  attention  is  paid  to  the  subject  under  their 
own  supervision.  They  only  serve  to  emphasize  the 
fact  that  personal  care  in  the  training  of  anesthetists 
is  needed  if  they  are  to  be  capable  of  assuming  this 
important  duty.  His  diploma  alone  justifies  no  man 
in  giving  an  anesthetic  unless  he  has  had  consider- 
able experience. 

Some"  of  the  expressions  of  opinion  in  this  matter 
are  so  strong  that  I  have  felt  that  I  am  justified  in 
quoting  them.  Dr.  Robert  Abbe  says :  "Judging 
by  the  flower  of  the  graduates  after  passing  exami- 
nations and  entering  hospital  service,  they  show  dan- 
gerous, ignorance."  Dr.  Joseph  D.  Bryant  says: 
"No,  nor  in  hospitals,  either."  Dr.  Joseph  B.  Hig- 
gins  says :  "Students  know  absolutely  nothing 
about  it."  Dr.  J.  B.  Murphy  says :  "I  not  only 
never  had  a  death,  but  never  saw  one.  In  Mercy 
Hospital,  where  I  do  most  of  my  operating,  the 
ether  is  administered  entirely  by  a  Sister  of  the 
Order  of  Mercy.  Occasionally  I  use  a  Bennett  evap- 
orator in  the  Presbyterian  Hospital.  There  the  work 
is  in  charge  of  a  physician  who  makes  a  specialty  of 


12 


anesthetics.  I  very  much  prefer,  however,  to  have 
a  woman,  and  preferably  not  a  physician. 

Of  course,  I  did  not  expect  very  frank  confes- 
sions with  regard  to  the  number  of  deaths  that  take 
place  and  have  taken  place  from  various  anesthetics. 
The  declaration  of  Dr.  Luke  that  chloroform  main- 
tains its  popularity  among  physicians  in  Scotland, 
because  there  are  no  coroner's  inquests,  is  extremely 
interesting  and  suggestive.  The  answers  to  this 
question  show  that  both  ether  and  chloroform  have 
their  dangers,  unless  properly  and  very  carefully  ad- 
ministered. 

Conclusions. —  (i)  Ether  is  more  generally  used 
than  chloroform,  because  it  is  safer. 

(2)  The  drop  method  of  administering  ether  is 
very  popular. 

(3)  Nitrous  oxide  is  preferred  as  a  preliminary 
to  ether  by  nearly  all  who  have  used  it  under  favor- 
able circumstances. 

(4)  Medical  colleges  do  not  place  enough  im- 
portance upon  anesthetics  and  their  administration. 

(5)  If  more  ether  and  less  chloroform  were  used, 
we  certainly  would  have  fewer  deaths. 

1025  Seventh  Avenue.  (Graham  Court.) 


13 


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